Modern laparoscopic surgery continues to move toward techniques that combine minimal access with precise operative control and improved patient experience. One area of ongoing innovation is laparoscopic appendectomy, where surgeons have explored different single-incision strategies to reduce the number of abdominal ports. WALS 2025 featured a comparative discussion of SIMPLA and SSMILA, two approaches that use a single incision but differ significantly in their access location and operative geometry.

SIMPLA stands for Single-Incision Multi-Port Laparoscopic Appendectomy, while SSMILA stands for Suprapubic Single-Incision Multi-Port Laparoscopic Appendectomy. The WALS 2025 material examines their technical characteristics, postoperative considerations, cosmetic implications, and potential role in the continuing development of minimally invasive appendectomy.

Why Single-Incision Appendectomy?

Conventional laparoscopic appendectomy normally requires several ports positioned at different points on the abdominal wall. This arrangement provides excellent triangulation and allows instruments to approach the appendix from different directions.

Single-incision surgery attempts to reduce the number of external access sites.

The concept has several potential attractions, including fewer visible scars and a different postoperative cosmetic profile. However, reducing the number of incisions can also make the operation technically more demanding because multiple instruments must work through a single entry point.

This creates an important balance between reduced access sites and increased technical complexity.

SIMPLA: The Umbilical Approach

SIMPLA generally uses a single umbilical incision through which multiple ports or channels are introduced.

The umbilicus is naturally positioned in a central abdominal location and has the advantage of providing a relatively concealed scar. Conventional laparoscopic instruments can be used, depending on the access system and surgeon's technique.

The principal challenge is instrument crowding.

When the camera and working instruments enter through the same region, the surgeon may experience reduced triangulation and external instrument interference. Experienced laparoscopic surgeons can adapt through changes in instrument positioning, camera orientation, and hand movements.

SSMILA: The Suprapubic Approach

SSMILA changes the location rather than simply modifying the umbilical access technique.

The single incision is positioned in the suprapubic region. One of the motivations is the possibility of placing the scar below the normal waistline or bikini line.

The approach also creates a different working angle. Instead of approaching the appendix from the central umbilical region, instruments enter from a lower abdominal location.

This can alter the ergonomics of dissection and may be useful in selected anatomical situations, while also creating its own technical challenges.

Comparing the Surgical Geometry

The most interesting aspect of the SIMPLA-versus-SSMILA comparison is the effect of access location on surgical geometry.

With SIMPLA, the surgeon works from the umbilical area. The appendix is generally located in the right lower abdomen, so instruments travel from a central access point toward the target.

With SSMILA, the access point is lower and closer to the pelvis. This changes the angle between the instruments and the appendix.

The difference may appear small externally, but it can significantly influence instrument manipulation inside the abdomen.

This is an important lesson in advanced laparoscopy: port placement is not merely an access decision—it is an ergonomic decision.

Cosmetic Outcomes

Cosmetic considerations are one of the major areas of interest in single-incision surgery.

The umbilical approach can conceal the scar within the natural contour of the navel. The suprapubic approach may conceal the scar below the waistline.

The WALS 2025 material specifically identifies cosmetic satisfaction as one of the areas considered in the comparison.

Patient preferences can vary considerably. Some patients may prefer a concealed umbilical scar, while others may prefer an incision located below the bikini line.

Consequently, cosmetic considerations should be discussed with patients as part of informed decision-making rather than assumed to be equally important to everyone.

Operative Time

Operative time is commonly used when comparing surgical techniques.

The WLH WALS 2025 material reports that SIMPLA was generally associated with shorter operative times in the comparative material, while SSMILA could require additional maneuvering because of its different access trajectory. It also notes that increasing surgeon experience may reduce the difference.

However, operative time should not be interpreted independently of patient complexity.

A straightforward case, perforated appendicitis, obesity, unusual appendix position, adhesions, or severe inflammation can all substantially influence operating time.

Postoperative Pain

Pain following laparoscopic appendectomy can be influenced by the location and size of the access incision, tissue handling, pneumoperitoneum, and individual patient factors.

The WALS 2025 comparison considered postoperative pain among its outcome parameters. The available material describes some differences between the two approaches, particularly during the early postoperative period.

The clinical importance of any difference should be considered in context, especially because pain is influenced by analgesic protocols and individual patient response.

Complications and Wound Considerations

Any modification of laparoscopic access must be evaluated for safety.

Potential complications include wound infection, bleeding, intra-abdominal abscess, port-site hernia, and other postoperative complications associated with appendectomy.

Umbilical and suprapubic incisions have different anatomical characteristics, so wound management and fascial closure require careful attention.

The WALS 2025 material discusses wound infection, incisional hernia, and intra-abdominal abscess among the comparative parameters.

The important principle is that minimizing visible scars should never take priority over adequate exposure and safe completion of the operation.

Anatomy Still Determines the Operation

Although the discussion focuses on access technique, the underlying pathology remains critical.

The appendix may be pelvic, retrocecal, subcecal, preileal, or postileal. Inflammation can also distort surrounding anatomy.

A single-incision approach that is straightforward in uncomplicated appendicitis may be more challenging when the appendix is perforated, densely adherent, retrocecal, or surrounded by inflammatory tissue.

Therefore, experienced surgeons must remain prepared to modify the operative plan when necessary.

Technical Skills Required

Single-incision appendectomy places particular demands on laparoscopic skills.

Important abilities include:

• Camera control
• Hand-eye coordination
• Instrument manipulation
• Traction and counter-traction
• Tissue dissection
• Control of the mesoappendix
• Secure management of the appendiceal base
• Specimen retrieval
• Recognition of unexpected anatomy
• Efficient instrument exchange

The surgeon must also become comfortable with the altered visual and mechanical relationships created by a single access site.

Training and the Learning Curve

The transition from conventional multi-port laparoscopy to single-incision surgery is not simply a matter of removing two ports.

The surgeon needs to understand how the reduction in triangulation changes instrument movement and how the location of the incision influences the operative field.

For SSMILA, the suprapubic access route adds another layer of adaptation because the surgeon must become familiar with the altered trajectory toward the appendix.

This reinforces the importance of structured training and supervised experience before adopting advanced techniques independently.

Patient-Centered Surgery

One of the most important themes emerging from the comparison is the concept of patient-centered surgical planning.

Patients may value different outcomes. Some may prioritize rapid recovery, some may focus on cosmetic appearance, while others may place greater importance on minimizing operative complexity or cost.

The surgeon's responsibility is to explain the available options, discuss relevant advantages and limitations, and select an approach appropriate to the clinical circumstances.

SIMPLA and SSMILA therefore provide examples of how modern surgery can be individualized rather than based on a single universal technique.

Future of Single-Incision Laparoscopy

The future development of single-incision surgery may be influenced by improvements in instruments and imaging.

Articulating laparoscopic instruments could improve maneuverability. Flexible cameras may provide greater visualization options. Advanced energy devices could simplify tissue dissection and haemostasis. Robotic systems may eventually address some of the ergonomic limitations associated with single-incision approaches.

Further research will also be important.

Future studies should evaluate standardized clinical outcomes, patient-reported satisfaction, long-term abdominal wall complications, operative efficiency, cost, and applicability across different patient populations.

WALS 2025 Perspective

The SIMPLA versus SSMILA discussion at WALS 2025 reflects the broader philosophy of the World Association of Laparoscopic Surgeons: minimally invasive surgery continues to evolve through experimentation, comparison, clinical experience, and technological innovation.

Rather than viewing laparoscopic appendectomy as a fixed operation, surgeons continue to investigate how access, visualization, instrumentation, and patient experience can be improved.

The WALS 2025 material provides an educational comparison of two approaches that share the same fundamental objective but use different access strategies.

Conclusion

The comparison of SIMPLA and SSMILA in laparoscopic appendectomy demonstrates how a seemingly simple change in incision location can influence the entire operative workflow.

SIMPLA uses the umbilical route and benefits from a naturally concealed access site, while SSMILA uses a suprapubic incision and offers a different operative trajectory with potential cosmetic advantages. Both approaches require appropriate training, careful patient selection, and a strong foundation in conventional laparoscopic surgery.

The WALS 2025 discussion is therefore valuable not only as a comparison of two appendectomy techniques but also as an example of how minimally invasive surgery continues to evolve through innovation in access, ergonomics, visualization, and patient-centered care.

For surgeons, gynecologists, surgical trainees, and medical professionals interested in advanced laparoscopy, this presentation offers an educational perspective on the technical possibilities and practical considerations surrounding single-incision laparoscopic appendectomy.